Provider Demographics
NPI:1760832885
Name:IRBY DENTAL COTTAGE
Entity Type:Organization
Organization Name:IRBY DENTAL COTTAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:IRBY
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:719-543-8808
Mailing Address - Street 1:2012 COMANCHE RD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-1405
Mailing Address - Country:US
Mailing Address - Phone:719-543-8808
Mailing Address - Fax:719-543-8808
Practice Address - Street 1:2099 WEST ST # 50
Practice Address - Street 2:SUITE 180
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008
Practice Address - Country:US
Practice Address - Phone:719-543-8808
Practice Address - Fax:719-543-8808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-20
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO903535124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty